RCOG advice

1. Diagnostic Laparoscopy
Consent Advice No. 2
June 2017

2. Diagnostic Laparoscopy
This is the third edition of this guidance, which was previously published in October 2004 and December 2008
under the same title.
This paper provides advice for clinicians in obtaining the consent of women undergoing diagnostic laparoscopy.
It follows the structure of Consent Form 1 of the Department of Health, England1
/Welsh Assembly
Government2
/Department of Health, Social Services and Public Safety, Northern Ireland.3
It should be used in
conjunction with Royal College of Obstetricians and Gynaecologists (RCOG) Clinical Governance Advice No.
6, ObtainingValid Consent.4
The aim of this advice is to ensure that all women are given consistent and adequate information for consent;
it is intended to be used together with a dedicated patient information leaflet.Printed/preprinted consent forms
should be considered to ensure that patients receive consistent information and so details of risk are not
omitted. It is recommended that the advice given in this guide should form the basis of these consent forms.
In addition, after discharge, all women should have clear direction to obtaining help if there are unforeseen
problems.
Clinicians should be prepared to discuss with the woman any of the points listed on the following pages. Risks
may be quantified using the descriptors below.
Table 1. Presenting information on risk
Term Equivalent numerical ratio Colloquial equivalent
Very common 1/1 to 1/10 A person in family
Common 1/10 to 1/100 A person in street
Uncommon 1/100 to 1/1000 A person in village
Rare 1/1000 to 1/10 000 A person in small town
Very rare Less than 1/10 000 A person in large town
The descriptors are based on the RCOG Clinical Governance Advice No. 7 Presenting Information on Risk,5
and are used throughout this
document.
To assist clinicians at a local level,a fully printable page 2 of the Department of Health,England1
/WelshAssembly
Government2
/Department of Health, Social Services and Public Safety, Northern Ireland,3
Consent Form 1 is
included at the end of this document.This page can be incorporated into local trust documents,subject to local
trust governance approval.
CONSENT FORM
1. Name of proposed procedure or course of treatment
Diagnostic laparoscopy,with or without minor treatment of problems that may be expected given the presenting
problem.This includes documentation of the findings that may include photographs or video that will be retained
as part of the patient records.
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3. 2. The proposed procedure
Describe the nature of laparoscopy.Explain the procedure as described in the patient information.This involves
the insertion of a laparoscope through a small incision on the abdominal wall to view the peritoneal cavity and
pelvic organs specifically in order to identify a cause for the patient’s symptoms.This involves the use of additional
small incisions to allow the use of instruments to move structure within the abdomen to allow a thorough
inspection and possible treatment if agreed in advance.
Potential minor treatments,such as dye hydrotubation,excision of mild superficial endometriosis,division of filmy
adhesions (bands of tissue) or tissue biopsy, should be discussed with the patient prior to surgery and
documented in the patient record and/or consent form.
Other procedures that might be anticipated (such as treatment of ovarian cysts, treatment of more severe
forms of endometriosis,thick or vascular adhesions) must be discussed and additional consent obtained specif-
ically with associated additional (risk of delayed presentation with the use of energy devices) risks discussed.
There is a possibility of finding conditions that require more extensive surgery.Therefore, an indirect risk is
establishing the need for more major gynaecological surgery at a later date once the patient has been able to
consider the consequences of that more major surgery. In these circumstances, small samples of tissue may be
taken for biopsy and analysis, but no disease modifying or curative surgery will be attempted.
3. Intended and potential benefits
To find the cause of the woman’s presenting symptoms.As this is a diagnostic procedure, it is unlikely to alter
symptoms. Occasionally, a minor laparoscopic procedure is appropriate to treat some of the identified causes
or relieve the symptoms.It might fail to achieve a diagnosis for the woman’s symptoms.It may not be appropriate
to perform more advanced surgery at the time of diagnostic laparoscopy as the patient may require time to
consider all further options depending on the findings of this test.
4. Significant and frequently occurring risks6–8
It is recommended that clinicians make every effort to separate serious from frequently occurring risks.Women
who are obese or very thin; who have significant pathology; who have had previous surgery; or who have pre-
existing medical conditions must understand that the quoted risks for serious or frequent complications will
be increased. The risk of serious complications at laparoscopy also increases if an additional therapeutic
procedure is performed.Women should also be advised that laparoscopy may not identify an obvious cause for
her presenting complaint.
4.1 Serious risks
These include:
● The overall risk of serious complications from diagnostic laparoscopy is approximately 2 in 1000 women
(uncommon).This includes damage to the bowel, bladder, ureters, uterus or major blood vessels which
would require immediate repair by laparoscopy or laparotomy (open surgery is uncommon). However, up
to 15% of bowel injuries might not be diagnosed at the time of laparoscopy.
● Failure to gain entry to the abdominal cavity and to complete the intended procedure.
● Hernia at site of entry (less than 1 in 100; uncommon).
● Thromboembolic complications (rare or very rare).
● Death; 3–8 in 100 000 women (very rare) undergoing laparoscopy may die as a result of complications.
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4. 4.2 Frequent risks
Frequent risks are usually mild and self-limiting.They may include:
● bruising
● shoulder-tip pain
● wound gaping
● infection.
5. Any extra procedures which may become necessary during the procedure
These may include:
● laparotomy
● repair of damage to the bowel (including the possibility of a stoma), bladder, uterus or blood vessels
● blood transfusion.
6. What the procedure is likely to involve, the benefits and risks of any available
alternative treatments, including no treatment
Insertion of a laparoscope through a small incision on the abdominal wall to view the peritoneal cavity and the
pelvic organs specifically to try and identify the cause of the woman’s symptoms.The role of prior diagnostic
imaging must be discussed, together with the option of no investigation.
7. Statement of patient: procedures which should not be carried out without further
discussion
Other procedures which may be appropriate but not essential at the time should be discussed and the woman’s
wishes recorded.
8. Preoperative information
A record should be made of any sources of information (such as RCOG or locally produced information leaflets;
https://www.rcog.org.uk/en/patients/patient-leaflets/) given to the woman prior to surgery.The RCOG produces
patient information on recovery after laparoscopic procedures, pelvic inflammatory disease, pelvic pain and
endometriosis.9–12
Doctors must enter into a dialogue with patients and be even more careful to give and document:13
● Clear and accurate advice on the risks and benefits of a procedure, and the alternatives.13
● Health service organisations should amend consent to treatment policies to reflect this development and
provide training to ensure that clinicians are aware of and follow the law.13
● Existing information sheets for procedures need to be reviewed to ensure they reflect the new position and
doctors should not rely solely on these when consenting patients.13
9. Anaesthesia
Where relevant,the woman must be made aware of the form of anaesthesia planned and be given an opportunity
to discuss this in detail with the anaesthetist before surgery.It should be noted that for women who are obese,
there are increased surgical and anaesthetic risks.
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5. References
© Royal College of Obstetricians and Gynaecologists
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Consent Advice No. 2
1. Department of Health. Reference guide to consent for
examination or treatment (second edition).London:DH;2009.
2. Welsh Assembly Government. Reference Guide for Consent
to Examination or Treatment. Cardiff:WAG; 2008.
3. Department of Health, Social Services and Public Safety,
Northern Ireland. Good Practice in Consent: Consent for
Examination,Treatment or Care. A handbook for the HPSS.
Belfast: DHSSPS; 2003.
4. Royal College of Obstetricians and Gynaecologists. Obtaining
Valid Consent.Clinical GovernanceAdvice No.6.London:RCOG;
2015.
5. Royal College of Obstetricians and Gynaecologists. Presenting
Information on Risk.Clinical GovernanceAdvice No.7.London:
RCOG; 2008.
6. Brosens I, Gordon A, Campo R, Gordts S. Bowel injury in
gynecologic laparoscopy. J Am Assoc Gynecol Laparosc
2003;10:9–13.
7. Chapron C, Querleu D, Bruhat MA, Madelenat P, Fernandez
H, Pierre F, et al. Surgical complications of diagnostic and
operative gynaecological laparoscopy:a series of 29 966 cases.
Hum Reprod 1998;13:867–72.
8. Jansen FW,Kapiteyn K,Trimbos-KemperT,Hermans J,Trimbos
JB. Complications of laparoscopy: a prospective multicentre
observational study. Br J Obstet Gynaecol 1997;104:595–600.
9. Royal College of Obstetricians and Gynaecologists.Acute pelvic
inflammatory disease.Information for you. London:RCOG;2016.
10. Royal College of Obstetricians and Gynaecologists. Chronic
(long-term) pelvic pain.Information for you. London:RCOG;2015.
11. Royal College of Obstetricians and Gynaecologists.
Endometriosis. Information for you. London: RCOG; 2016.
12. Royal College of Obstetricians and Gynaecologists.Recovering
well: Information for you after a laparoscopy. London: RCOG;
2015.
13. Montgomery (Appellant) v Lanarkshire Health Board
(Respondent) (Scotland) [2015] UKSC 11 [https://www.
supremecourt.uk/cases/uksc-2013-0136.html].

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Appendix I: Diagnostic laparoscopy consent to treatment form
Patient identifier/label ………………………………………………………………………………………
Name of proposed procedure or course of treatment (include brief explanation if medical term not clear)
Diagnostic laparoscopy with or without minor treatment.
Statement of health professional (to be filled in by health professional with appropriate knowledge of the proposed procedure, as
specified in the consent policy)
I have explained the procedure to the patient with other possible alternatives including conservative options.
In particular, I have explained:
The intended benefits
To find the cause of symptoms although sometimes no cause may be found.As this is a diagnostic procedure, it
is unlikely to alter symptoms. Occasionally, a minor laparoscopic procedure is appropriate to treat some of the
identified causes or relieve the symptoms.
Serious risks
● The overall risk of serious complications from diagnostic laparoscopy is approximately 2 in every 1000
women (uncommon).This includes damage to the bowel, bladder, uterus or major blood vessels which
would require immediate repair by laparoscopy or laparotomy (uncommon). However, up to 15% of bowel
injuries might not be diagnosed at the time of laparoscopy.
● Failure to gain entry to abdominal cavity and to complete intended procedure.
● Hernia at site of entry (less than 1 in 100; uncommon).
● Thromboembolic complications (rare or very rare).
● Death; 3–8 in 100 000 women (very rare) undergoing laparoscopy may die as a result of complications.
Frequent risks
● bruising
● shoulder-tip pain
● wound gaping
● infection.
Any extra procedures which may become necessary during the procedure
● Laparotomy
● Repair of damage to the bowel (including the possibility of a stoma), bladder, uterus or blood vessels
● Blood transfusion
● Other procedure ( please specify) …………………………………………………………………………
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative
treatments (including no treatment) and any particular concerns of this patient.
The following patient information leaflet has been provided: Laparoscopy (https://www.rcog.org.uk/
en/patients/patient-leaflets/laparoscopy/) available from the RCOG.
This procedure will involve
n General and/or regional anaesthesia n Local anaesthesia n Sedation
Signed …………………………………………………………………………… Date ……………………
Name (print) …………………………………………………………… Position …………………………

7. Contact details (if patient wishes to discuss options later)
……………………………………………………………………………………………………………………
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe
they can understand.
Signed ……………………………………………………………………………… Date ……………………
Name ( print) ……………………………………………………………………………………………………
Top copy accepted by patient Yes / No (please circle as appropriate)
Confirmation of consent (to be completed by a healthcare professional when the patient is admitted for the
procedure, if the patient has signed the form in advance). On behalf of the team treating the patient, I have
confirmed with the patient that they have no further questions and wish to proceed.
Signed …………………………………………………………………………… Date ……………………
Name (print) …………………………………………………………… Position …………………………
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8. The guideline will be considered for update 3 years after publication, with an intermediate
assessment of the need to update 2 years after publication.
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DISCLAIMER
The Royal College of Obstetricians and Gynaecologists produces Consent Advice as an aid to good clinical practice.The
ultimate implementation of a particular clinical procedure or treatment plan must be made by the doctor or other attendant
after the valid consent of the patient in the light of clinical data and the diagnostic and treatment options available.The respon-
sibility for clinical management rests with the practitioner and their employing authority and should satisfy local clinical
governance probity.
This Consent Advice was produced on behalf of the Royal College of Obstetricians and Gynaecologists by:
Mr S Banerjee FRCOG, Cambridge; Mr KS Arambage MSc, MRCOG, Oxford; MrTA Smith Walker MRCOG,
Truro
and peer reviewed by:
Professor I Brosens FRCOG, Leuven, Belgium; Mrs A Diyaf MRCOG, Barnstaple; Mr D Fraser FRCOG, Norwich;
Professor K Ismail FRCOG, Birmingham; Mrs K Morley, Royal Hampshire County Hospital,Winchester;
Mr EP Morris FRCOG, Norwich; RCOG Women’s Network; Mr SVyas FRCOG, Bristol.
The Joint Standing Committee for Patient Safety lead reviewer was: Mr TC Hillard FRCOG, Poole.
The chair of the Joint Standing Committee for Patient Safety was: Mr TC Hillard FRCOG, Poole.
All RCOG guidance developers are asked to declare any conflicts of interest.A statement summarising any conflicts of interest for this
Scientific Impact Paper is available from: https://www.rcog.org.uk/en/guidelinesresearch-services/guidelines/ca2/.
The final version is the responsibility of the Joint Standing Committee for Patient Safety of the RCOG.